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n e w e ng l a n d j o u r na l
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Review Article
DanL.Longo,M.D.,Editor
Fibrosis
Eye
Strabmisus
Pulmonary fibrosis
Restrictive lung disease
Pulmonary hypertension
Right-sided heart failure
Skin
Scleroderma
Keloid
Nephrogenic systemic fibrosis
Cardiac fibrosis
Diastolic dysfunction
Heart failure, with reduced
or preserved ejection fraction
Arrhythmia
Pancreatic fibrosis
Chronic pain
Diabetes mellitus
Malabsorption
Cancer
Cirrhosis
Portal hypertension
Ascites
Gastroesophageal varices
Hepatorenal syndrome
Hepatopulmonary syndrome
Portopulmonary syndrome
Hepatic encephalopathy
Hepatocellular cancer
Hypertension
Anemia
Electrolyte disturbances
Renal fibrosis
cluding lymphocytes, polymorphonuclear leukocytes, eosinophils, basophils, mast cells, and macrophages. These inflammatory cells elicit the
activation of effector cells,1 which drive the fibrogenic process. One example in which an inflammatory lesion drives this cycle is the interstitial
nephritis induced by nonsteroidal antiinflammatory drugs (NSAIDs), which culminates in chronic
inflammation and the activation of a fibrogenic
cascade. In addition, macrophages can play a
prominent role in interstitial fibrosis, often driven
by the TGF- pathway.2 However, some inflammatory cells may be protective. For example,
n engl j med 372;12
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Inciting injury
Epithelial
cell
Injured
epithelial cell
Basement
membrane
Recruitment of
inflammatory cells
T cells
Cellcell
interaction
Macrophage
Effector cell
Effector-cell
proliferation
NK cells
Injured
endothelial cell
Cytokines
Effector-cell
activation
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Fibrosis
Cytokines
Growth
factors
Integrins
TGF-
receptor
Vasoactive
peptides
Extracellular matrix
biosynthesis
Fibrogenic
effector cell
MAPKs
Rho/ROCK
SMADs
Integrin-linked
kinase
Nucleus
Figure 3. Molecular Pathways in Fibrosis.
Fibrogenesis in multiple tissues is effected by a number of signaling cascades. These cascades (not shown) are often triggered by the exposure of effector cells to circulating or locally produced molecules that stimulate the biosynthesis and secretion of extracellular matrix proteins. The extracellular matrix itself may also stimulate fibrogenesis
through activation of integrin signaling. Examples of major pathways are shown. MAPK denotes mitogen-activated
protein kinase, ROCK Rho-associated protein kinase, and TGF- transforming growth factor .
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In diabetic nephropathy, TGF- promotes the expression of miR-192, which results in collagen deposition,31 and miR-19b regulates TGF- signaling
in hepatic stellate cells.32 In the heart, miR-21,
miR-29, miR-30, and miR-133 participate in the
remodeling of the myocardial matrix.33
Mech a nisms a nd A dv er se
Cl inic a l Effec t s
Cardiac Fibrosis
The heart undergoes extensive structural and functional remodeling in response to injury, central to
which is the hypertrophy of cardiac myocytes,
with excessive deposition of extracellular matrix.34
Myocardial fibrosis is commonly categorized as
one of two types: reactive fibrosis or replacement
fibrosis. Reactive fibrosis occurs in perivascular
spaces and corresponds to similar fibrogenic responses in other tissues; replacement fibrosis occurs at the site of myocyte loss.
In the heart, fibrosis is attributed to cardiac
fibroblasts, the most abundant cell type in the
myocardium. These cells are derived from fibroblasts that are native to the myocardium, from
circulating fibroblasts, and from fibroblasts that
emerge from epithelial-to-mesenchymal transition.35,36 All these cell types proliferate and differentiate into myofibroblasts in response to
injury (Fig.2), a process that is driven by classic
factors such as TGF-1, endothelin-1, and angiotensin II.37 Cross-talk and feedback also occur
between cells in this case, between activated
fibroblasts and cardiomyocytes which further
fuel fibrogenesis.38
Cardiac fibrosis contributes to both systolic and
diastolic dysfunction and to perturbations of electrical excitation; it also disrupts repolarization
(Fig.1).39 Proarrhythmic effects are the most
prominent. Collagenous septa in the failing heart
contribute to arrhythmogenesis by inducing a
discontinuous slowing of conduction.40 Areas of
arrhythmogenic fibrosis slow conduction through
junctions in the heterocellular gap that couple
fibroblasts and cardiomyocytes.41 Endocardial
breakthrough of microreentrant circuits occurs as
a result of the heterogeneous spatial distribution
of fibrosis42 and the triggering of activity caused
by the depolarization of myocytes by electrically
coupled myofibroblasts.43
Fibrotic scarring in the heart correlates strongly with an increased incidence of arrhythmias
Fibrosis
Hepatic fibrosis typically results from an inflammatory process that affects hepatocytes or biliary
cells. Inflammation leads to the activation of effector cells, which results in the deposition of
extracellular matrix. Although a variety of effectors synthesize extracellular matrix in the liver,
hepatic stellate cells appear to be the primary
source of extracellular matrix. Abundant evidence
suggests that the stellate cell is pericyte-like, undergoing a transformation into a myofibroblast in
response to injury.10
In the liver, multiple cell types, including stellate cells, endothelial cells, Kupffer cells, bile-duct
cells, and immune cells, orchestrate the cellular
and molecular response to injury.46 Numerous molecular pathways, similar to those found in other
organs, are involved. A pathway that appears to
be unique to the liver involves toll-like receptor 4
(TLR4)47; TLR4 is activated on the surface of stellate cells by intestinal bacterial lipopolysaccharides derived from the gut (i.e., translocated bacteria), triggering cell activation and fibrogenesis
and thereby linking fibrosis to the microbiome.48
TLR4 expression is associated with portal inflammation and fibrosis in patients with fatty liver
disease.49
The end result of hepatic fibrogenesis is cirrhosis, an ominous parenchymal lesion that underlies
a wide range of devastating complications that
have adverse effects on survival (Fig.1). Portal
hypertension, a devastating result of injury, develops during the fibrogenic response after disruption of the normal interaction between sinusoidal endothelial cells and hepatic stellate cells;
the resulting activation and contraction of pericyte-like stellate cells leads to sinusoidal constriction and increased intrahepatic resistance. This
increase in resistance in turn activates abnormal
signaling by smooth-muscle cells in mesenteric
vessels. An increase in angiogenesis and collateral
blood flow follows, resulting in an increase in
mesenteric blood flow and a worsening of portal
hypertension.50 The major clinical sequelae of portal hypertension, variceal hemorrhage and ascites,
Events that initiate renal fibrosis are diverse, ranging from primary renal injury to systemic diseases.51,52 The kidneys are susceptible to hypertension and diabetes, the two leading causes of
renal fibrosis. As is true in other organs, fibrosis
of the kidney is mediated by cellular elements
(e.g., inflammatory cells) and molecular elements
(e.g., cytokines, TGF-1, CTGF, PDGF, and endothelin-1) (Fig.2 and 3).51-54 The intrarenal renin
angiotensinaldosterone axis is particularly important in hypertension-induced fibrosis.54
The kidney has a unique cellular architecture
that consists of the glomeruli, tubules, interstitium, and capillaries. Injury at any of these sites
triggers the deposition of extracellular matrix.37
The location of the initial injury is an important
determinant of the clinical consequences. Injuries that initially target glomeruli elicit patterns
of disease that are different from those that are
elicited by injuries to the tubularinterstitial environment. For example, NSAIDs, urinary obstruction, polycystic kidney disease, and infections
can provoke tubulointerstitial fibrosis,43 whereas
glomerular immune deposition (e.g., the deposition of IgA) leads to glomerulonephritis.44 Glomeruli and podocytes are sensitive to systemic and
local immunologic insults45; high glomerular capillary pressure, exacerbated by systemic hypertension and diabetes, leads to proteinuria, the
activation of cytokines and complement, and the
infiltration of immune cells, resulting in epithelial cell and interstitial fibrosis.46
Glomerular fibrosis, regardless of the cause,
diminishes renal blood flow, which leads to
hypoxia and the activation of hypoxia-inducible
factor 1, which in turn triggers nephron collapse
and fibrotic replacement by means of rarefaction.47
The renal interstitium and capillaries contribute
substantially to tubulointerstitial disease, as peritubular pericytes migrate into the interstitium,
where they are transformed into myofibroblasts.48
Regardless of the initiating insult, renal fibrosis leads to loss of function and organ failure
(Fig.1). Homeostasis can be maintained with a
glomerular filtration rate as low as approximately
10% of the normal rate. As the mechanisms maintaining homeostasis are progressively disrupted,
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anemia develops and the regulation of electrolyte blasts and myofibroblasts are activated through
balance and pH is disrupted.
the TGF-SMAD signaling pathway.60 Nephrogenic systemic fibrosis, a debilitating condition
Pulmonary Fibrosis
that is marked by widespread organ fibrosis, ocPulmonary fibrosis occurs in association with a curs in patients with renal insufficiency who have
wide range of diseases, including scleroderma (sys- been exposed to gadolinium-based contrast matemic sclerosis), sarcoidosis, and infection, and terial. Initial systemic inflammatory-response
as a result of environmental exposures (e.g., silica reactions and the reaction of gadolinium (Gd3+)
dust or asbestos), but in most patients it is idio- ions with circulating proteins and heavy metals
pathic and progressive. Idiopathic pulmonary lead to the deposition of insoluble elements in
fibrosis is characterized by progressive fibrosis tissue.61 Since no effective therapies have been
without substantial inflammation.55 Its patho- identified, prevention is key.61 A recently recoggenesis appears to be unlike that of other fibros- nized IgG4-related disease appears to involve
ing diseases and is poorly understood. Injury to autoimmune-driven inflammation that provokes
alveolar epithelial cells activates pulmonary fibro- fibrosis in multiple organs, including the pancreas,
blasts, provoking their transformation to matrix- retroperitoneum, lung, kidney, liver, and aorta.62
producing myofibroblasts.56 Activated lung fibroblasts may cause apoptosis of alveolar cells, which
Ther a py
leads to further fibroblast activation and a vicious
cycle of injury and effector-cell activation (Fig.2). Fibrosis and resultant organ failure account for
Research has focused on TGF- signaling (Fig.3)57 at least one third of deaths worldwide.63 Since
and the interstitial pericytes present in lung fi- fibrosis is common and has adverse effects in all
brosis.58
organs, it is an attractive therapeutic target. ConPulmonary fibrosis is characterized by paren- trary to the widely held perception that scar tissue
chymal honeycombing, reduced lung compliance, is permanent, the available evidence points to the
and restrictive lung function (Fig.1). Fibrosis of highly plastic nature of organ fibrosis; it is not
the interstitial spaces hinders gas exchange, cul- irreversible scar but an actively remodeled tisminating in abnormal oxygenation and clinical sue component that can, under certain circumdyspnea. Progressive pulmonary fibrosis also leads stances, regress. Fibrosis occurs by means of a
to pulmonary hypertension, right-sided heart fail- dynamic process that involves the synthesis and
ure, and ultimately respiratory failure.
deposition of extracellular matrix, and its reversion occurs by means of the elimination of efOther Forms of Fibrosis
fector cells and shifts in the balance of matrix
Fibrosis also occurs in the joints, bone marrow, synthesis and degradation (Fig.4). Although it is
brain, eyes, intestines, peritoneum and retroperi- not clear what pathogenic or clinical factors protoneum, pancreas, and skin, and in these cases mote reversibility, the regression of fibrosis has
is driven by typical cellular and molecular pro- been shown to lead to improved clinical outcomes.
cesses (Fig.2 and 3). Retroperitoneal fibrosis is Elimination of the inciting stimulus is the first
a rare condition characterized by inflammation and most efficacious approach.
and fibrosis in the retroperitoneal space; most
Fibrosis of parenchymal tissue usually procases are idiopathic, but secondary causes include gresses slowly, which suggests that therapy may
drugs, infections, autoimmune and inflammatory be required for extended periods; slowing the prostimuli, and radiation. Patients may present with gression of fibrosis may be a more realistic therapain, and the major clinical sequelae of this con- peutic goal than eliminating it. One of the chaldition are related to its involvement with struc- lenges in assessing the therapeutic response is that
tures in the retroperitoneum, including arteries there are few noninvasive means of measuring fi(leading to acute and chronic renal failure) and brosis (e.g., blood or imaging tests; biopsy is typiureters (leading to hydronephrosis). Currently, cally the most reliable approach) or monitoring the
treatment of this primary fibrosing disorder is effects of therapeutic intervention.
not available. In certain cancers, fibrosis is linked
The best indication that fibrosis is reversible
to TGF--integrin signaling.59 In scleroderma, the and that this reversibility has positive effects on
prototypical fibrosing skin disease, skin fibro- clinical outcomes is based on the treatment of
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Fibrosis
in terms of the goal to specifically confront fibrosis. Novel approaches to the treatment of fibrosis
that are based on an extensive body of preclinical data are anticipated in the coming years (see
Table S2, which highlights early phase trials that
target less well established, although potentially
important, pathways in fibrosis).
Heart
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Diseases
Drugs
Summary of Effectiveness
Source of Data
Heart
Heart failure, cardiomyopathy, hypertrophic cardiomyopathy, cardiomyopathy induced by type 2 diabetes, heart failure or cardiomyopathy induced by
hypertension
Spironolactone, epler
enone, canrenone, pirfenidone, sildenafil,
statins, ACE inhibitors,
ARBs, torsemide, MRAs
Liver
Kidney
Lambers Heerspink
et al.,79 Ruggenenti et
al.,80 Bonventre,81
Guney et al.,82 Sharma et al.,83 de Zeeuw
et al.84
Lung
Skin
Pirfenidone, interferon
-1b, bosentan, ambrisentan, macitentan, nintedanib, acetylcysteine
* ACE denotes angiotensin-converting enzyme, ARB angiotensin-receptor blocker, cGMP cyclic guanosine monophosphate, MRA mineralocorticoid-receptor antagonist, MRI magnetic resonance imaging, Nrf2 nuclear factor erythroid 2related factor, PPAR peroxisome proliferatoractivated receptor, RAS reninangiotensin system, and TGF- transforming growth factor beta.
Detailed information about specific trials is provided in Table S1 in the Supplementary Appendix.
fibrosis is based on the premise that cardiac fibroblasts can be reprogrammed into cardiomyocyte-like cells95,96 (Table S2 in the Supplementary
Appendix) that would promote normal tissue regeneration; in a murine model of myocardial
infarction and fibrosis, the retroviral expression
of specific transcription factors in the myocardium reprogrammed cells that acquired spontaneous contractile and electrophysiological properties resembling those of cardiomyocytes, leading
to global improvements in contractile function.
It is not yet known whether this type of therapy
can be used in humans.
Kidney
Liver
Fibrosis
versed.66,99-101 Eradication of HCV infection, antiviral therapy for HBV infection, glucocorticoid
therapy for autoimmune hepatitis, phlebotomy
for hemochromatosis, relief of biliary obstruction,
and cessation of alcohol consumption in alcoholic hepatitis each clearly reverses fibrotic change,
and many of these treatments improve clinical
outcomes.66,99,100,102
A number of potential antifibrotic therapies
targeting specific pathways have been studied in
human liver disease (Table S2 in the Supplementary Appendix). For example, colchicine suppresses
collagen secretion and theoretically prevents fibrosis.46 Interferon -1b and the peroxisome
proliferator-activated receptor ligand, farglitazar, which inhibit stellate cell-mediated fibrogenesis, were studied in patients infected with
HCV that was unresponsive to primary antiviral
therapy, but no beneficial effects on fibrosis
were noted.46 Other agents, including polyenephosphatidyl choline, silymarin, and ursodeoxycholic acid, have similarly shown no benefit.46
Vitamin E had modest effects on histologic fibrosis in patients with nonalcoholic steatohepatitis.72
Lung
F u t ur e Dir ec t ions
Fibrosis is a hallmark of pathologic remodeling
in numerous tissues and a contributor to clinical
disease. There is a great deal of interest in identifying means of slowing, arresting, or even reversing the progression of tissue fibrogenesis.
Thus, it is important to understand the central
mechanisms underlying the fibrogenic process.
Common themes implicating conserved cellular
and molecular pathways have emerged. A major
conserved cellular element is the activated fibroblast, also known as a myofibroblast, which produces abundant amounts of extracellular matrix.
Some of the major conserved molecular processes
involve TGF-, PDGF, CTGF, vasoactive compounds
(endothelin-1 and angiotensin II), and integrin
extracellular matrix signaling pathways. The fact
that tissue fibrosis is remarkably plastic suggests
that many of these major elements of disease
pathogenesis may emerge as targets of novel
therapeutic interventions.
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
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